A rationale for the routine use of transverse abdominal incisions in infants and children

A Rationale

for the Routine Use of Transverse Incisions in Infants and Children ByMichael

0 Although are

valued

newborn, support

The

transverse for

their

infant,

abdominal

excellent

and

child,

abdomens

of 80 infants

infants

and correlated

with

that the younger abdominal

were

have been and

children

measured

growth.

and

It was

Ohio

(TAI)

The remaining

in

the to

lacking. and

11

evaluated larger the

cal differences

between

the cavity of the latter resembles

horizontally greater

oriented

exposure.

proportionately

the abdomen

The younger

a

TAI give

the child, the larger

was the costoiliac

easier lateral extension

space,

considered

different

separately.

hospital patients

infants whose measure-

proportions

The

sample

(all prematures

without abdominal

and

were

therefore

was comprised

of in-

and some older children

lesions), office patients with minor surgiwas that of

No child was markedly

obese or cachectic

and none had

abdominal wall defects or abdominal distention.

of adults and

ellipsoid; accordingly.

1 I were premature

revealed

the local population in terms of length, weight, sex, and race.

of the anatomi-

small children,

ments

cal lesions, and healthy children. The distribution

demonstrated

the child, the relatively

cavity and wall. Because

W. L. Gauderer

Cleveland.

measurements

this clinical impression

premature

incisions

exposure

Abdominal

allowing

of the incision, if necessary.

The measurements circumference ference

employed

were length, weight, chest

at the level of the nipples, abdominal

at the level of the umbilicus,

xiphoumbilical

circum(AC),

bicostal

(DE--costal

margin

level of the anterior

axillary

line),

(FG---anterior

superior

and

iliac

(AB),

xiphopubic

spine)

biiliac

costoiliac

at the

(DF-EC-from

the

The umbilicus is low in infants and small children and

lowest point of the costal margin to the highest point of the

the transverse

iliac crest-at

supraumbilical

over the anatomical The

conclusion

drawn

child, the greater

incision may be placed

center of the abdominal was

that

the

younger

the rationale for routinely

ing transverse

abdominal

INDEX WORD:

Transverse

cavity. the

employ-

abdominal

I ).

line) (Fig.

of the Computer

Reserve University

Unix

System

All measure-

were plotted and

the respective curves drawn using the BMDOSD program

incisions.

the midaxillary

ments were taken twice. The measurements

general plot

of Case Western

(Figs. 2 and 3).

incisions.

RESULTS

Group A: Full Term to 16 yr INCE celiotomy is an integral part of a surgical procedure, it deserves the same care in its choice and execution as the treatment of the intraabdominal lesion to which it gives access. Although the controversy concerning use of transverse or vertical abdominal incisions in incision is adults continues,’ 9 the transverse commonly preferred by pediatric surgeons.” I3 The incision of choice should be the one that provides optimal exposure with minimal trauma, allows extension, if necessary, and provides greater tensile strength while maximizing both patient comfort and cosmetic end result. Operative exposure and the possibility of adequate extension of the incision are necessarily related to the diameter or the general shape of the abdominal wall and cavity. In this study, the topography of the abdominal wall was correlated with growth to demonstrate that the abdomen of the infant is not only proportionately larger than that of the older child and adult, but also greater in its transverse diameter.

S

MATERIALS Ninety-one

AND

age to 16 yr.

1 (August).

198 1

Infants

Although the curves were different, the same general trend was observed when plotted. The abdominal measurements do not have the same slope as the body lengths and weights. Since the majority of the abdominal parameters possess the same slope, it can be concluded that the younger the child, the relatively larger the abdominal cavity and wall.

From the Division o! Pediatric and

Childrens

Cleveland:

Hospital

reprint

2101 Adelbert

o 1981

of

by Grune

Surgery,

the

and the Department

Reserve University, M.D..

children were divided into two groups. Eighty

Journal of Pediatric Surgery, Vol. 16, No. 4, Suppl.

Group B: Premature

Address

METHODS

of these ranged between 40 wk of gestational

When compared to the standard growth curves (height and weight), the curves corresponding to the measurements of the abdominal wall show a much smaller slope. The most striking measurement was the costoiliac (DF-EC), where there was practically no growth.

of Biometry.

School of Medicine, requests

Ohio

Babies

Hospitals

of

Case Western

Cleveland,

to Michael

Road, Cleveland. & Stratton.

Rainbow

University

Ohio.

W. L. Gauderer. 44lOb.

Inc.

0022-3468/81/1607-0009$01.00/0

583

584

MICHAEL W. L. GAUDERER

180 ,’

170

2.

Fig. 1. Diagram of infant identifying the sites of the measurements: AC, xiphopubic; AB, xiphoumbilical; DE. bicostal: FG, biiliac; DF-EG, costoiliac. The tension lines of the skin in infants are also depicted according to Hutchinson and Koop.”

DISCUSSION

Transverse abdominal incisions (TAI) have been described and employed for over 150 yr.3,7.‘2 Interest in this type of incision for operations other than pelvic or appendicular is less than 50 yr old.7~‘5-‘7 In 1952, Gross and Ferguson” recorded some of the advantages of TAI. Campbell and Swenson” expanded these findings by adding their report of the lower incidence of wound dehiscence in children using TAI and the gridiron incision. There exists a considerable amount of additional literature supporting TAI over vertical incisions (VI), particularly in the Some of these advantages include adult. ‘~2~4-9~‘5~‘7 superior exposure,‘.‘5,‘6 fewer postoperative complications, greater patient comfort,2*4’9 and a decreased incidence of wound dehiscence.2.‘o.‘5*‘6.22Although most authors believe

Age

,’

,’ I’ 1

(months)

Fig. 2. Curves obtained in the measurement of 80 infants and children: 1. length, 2. weight, 3. chest circumference, 4. abdominal circumference, 5. xiphopubic, 6. biiliac, 7. bicostel, 8. xiphoumbilical, 9. costoiliac. Notice the direction of the curves related to growth (1 and 2) as compared to those of the abdominal parameters (4-9); especially the almost horizontal line corresponding to the costoiliac distance.

that TAI provide greater tensile strength,“.* there is some disagreement on this point.5 Despite the fact that gridiron and TAI have been shown to be superior to vertical celiotomies in both children and adults,‘.‘“~‘5.‘6.‘” two commonly employed atlases of pediatric surgery still depict VI for laparotomies.‘9.20 One atlas2’ shows both horizontal and vertical incisions, while another recent atlas condemns vertical celiotomies in infants especially those in the midline.22 A current atlas of neonatal surgery clearly demonstrates a preference for TA1.2’ Other authors agree that the midline verticle incision is least appropriate for infants”b’2.‘x because of the greater occurrence of weak and diastatic lineae alba, umbilical and supraumbilical hernias. When deliberating a surgical approach to an intraabdominal lesion in a child, the prime

585

TRANSVERSE ABDOMINAL INCISIONS

IOOr

5-

___-_---__.._____.-..-.-

_____-_---.___._.__--

0---r

I

28

r

Weeks

3.

I

i2

;lj

(gesta tional

-%

~-7~ age 1

Fig. 3. Curves obtained in the measurement of 11 premature children: 1. length, 2. weight. 4. abdominal circumference. 5. xiphopubic. 6. biiliac. 7. bicostal, 8. xiphoumbilical. 9. costoiliac.

consideration should be adequate surgical exposure, and attainment of this goal is directly related to the shape of the abdomen. As the child grows, the shape and size of the abdomen changes considerably in relationship to the rest and small of the body.14 Infants, prematures. children particularly have a disproportionately large abdomen and liver.“~‘4 In addition, our measurements illustrate that the transverse diameter is more pronounced in infants, giving an ellipsoidal shape to the abdominal cavity (Fig. 4). Space is limited for inferior extension of VI (especially in the midline) because of the small pelvis and intraabdominal bladder. The proportionately large costoiliac space

Fig. 4. Drawing based on a photograph of a formalized infant cadaver (Heiderich’*l. showing the large liver. the high bladder, and the horizontally oriented intestinal loops.

facilitates the lateral extension of transverse incisions. The low position of the umbilicus in infants allows placement of the transverse supraumbilical incision in the anatomical center of the abdomen, making this celiotomy almost universally applicable when a precise diagnosis cannot be established. Additional advantages are that there is virtually no need for autostatic retractors, especially if a roll is placed behind the child’s back. Also, relatively less relaxation is needed. The cosmetic advantages of placing the incision in the tension lines of the skin” are well recognized.l~~7~“~l2~l6-‘8

ACKNOWLEDGMENT I am particularly indebted to Joanne Horst, P.A.C., and Ann Merrell

for their aid in the preparation

of this paper.

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